Domestic Or Household Employees: Job Description Form

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Domestic or Household Employees:
Job Description Form
(Statement of Job Conditions)
An Employment Agency must give a completed Job Description Form with all of the information below to
every job applicant the Agency refers to a position as a Domestic or Household Employee.
Date _____/_____/_____
Amount of Fee $ __________
Employment Agency Information
Name of Employment Agency ____________________________________________________________
Name of Agency Staff ___________________________________________________________________
Telephone Number ______________________________ DCA License Number ____________________
Address ______________________________________________________________________________
Job Information
Name of Employer _____________________________________________________________________
Telephone Number _______________________________ Email Address _________________________
Address ______________________________________________________________________________
Employer will provide (check box that applies):
Hourly Pay Rate $ ___________
No meals
(minimum $9.00/hour)
One meal per working day
Two meals per working day
Lodging: Live In
Live Out
Three meals per working day
Start Date _____/_____/_____
_____ Hours/Day
Employment Status (check all that apply):
Weekly Schedule (check all that apply):
Part-time
Monday
Full-time
Tuesday
Wednesday
Temporary
Thursday
Permanent
Friday
Saturday
Sunday
Description of Duties _________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Updated 1/2016

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